Healthcare Provider Details

I. General information

NPI: 1265574461
Provider Name (Legal Business Name): VANPRASEUTH FONGNALY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 03/28/2025
Certification Date: 03/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 WORNALL RD
KANSAS CITY MO
64111
US

IV. Provider business mailing address

901 E 104TH ST MAILSTOP 400S
KANSAS CITY MO
64131
US

V. Phone/Fax

Practice location:
  • Phone: 816-932-3679
  • Fax: 816-932-9089
Mailing address:
  • Phone: 816-502-8782
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2014025191
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberD0068983
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberCDRH.0068942
License Number StateCO
# 4
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number3724
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: